Methods/results
We report the case of a 31-year-old female with a history of IVDU and
chronic hepatitis C who presented to the hospital with a fever and back
pain. She had previously left an outside hospital against medical
advice, where she had been found to have MSSA bacteremia. Upon arrival
at our ED, a CT angiogram found septic pulmonary emboli, raising
suspicion of IE. Transthoracic echocardiogram (TTE) showed a tricuspid
valve (TV) vegetation with severe tricuspid regurgitation. The patient
underwent bioprosthetic TV replacement, followed by 6 weeks of
cefazolin. She also received two epicardial pacing leads and a permanent
pacemaker during the procedure for heart block. After discharge, the
patient was only seen once before being lost to follow-up.
7 months later, the patient returned to our ED with fatigue, fevers,
night sweats, chronic back pain, shortness of breath, and reported
heroin usage prior to presentation. TTE revealed recurrent TV vegetation
with severe regurgitation and secondary ventral septal defect (Figure 1.
A, B). She was admitted to the cardiology service in the ICU and despite
maximal medical management, deteriorated with severe cardiogenic and
septic shock due to persistent bacteremia. Ten days into ICU care she
became anuric in spite of inotropic support. Cardiac surgery service was
consulted as hospice care was being considered. Upon evaluation, the
patient was deemed very high risk and a poor candidate for redo
sternotomy and tricuspid valve replacement without infection source
control. We planned a staged approach with the initial stage of
valvectomy for source control and ECMO for hemodynamic stability to
definitive treatment. After a redo sternotomy and tricuspid valvectomy,
she was placed on venous arterial ECMO with right femoral arterial
cannulation, allowing time for possible infection clearance, right heart
decompression, and hepatic decongestion (Figure 1. C, D). After 7 days,
repeated blood cultures showed bacteremia clearance and return to
hemodynamic stability with resolving renal failure. The patient was
taken back to the operating room and underwent 29 mm bioprosthetic valve
replacement, ventral septal defect (VSD) repair, and new epicardial lead
placement (Figure 1. E, F).
The patient had a prolonged subsequent at the hospital due to developing
sacral debutis pressure ulcer, placement concerns due to extensive
history of polysubstance use disorder, depression/anxiety, and
post-traumatic stress disorder, and the requirement of intravenous
antibiotics. At the end of her hospitalization, the patient agreed to be
discharged to a long-term acute care hospital, after which she would
continue with methadone and buprenorphine treatments as well as
receiving significant physical therapy, speech therapy, and nutritional
support. This study was approved by IRB (ID: 2000020356) on 4/4/2022 and
written with the informed consent of the patient.